Op-Ed: More Not Always Better When Treating Cancer
NEAL CONAN, host: Some cancer doctors recommend aggressive, even extremely aggressive surgery. In an op-ed in today's New York Times, Dr. Barron Lerner warns that more isn't always better. He cites a procedure more and more doctors use in which patients first undergo surgery to remove any visible cancer, then have heated chemotherapy pumped into the abdominal cavity for 90 minutes to kill any remaining cells. He also says there's almost no evidence that this HIPEC procedure is any more effective than traditional chemotherapy.
We want to hear from doctors and cancer patients who considered what Dr. Lerner calls extreme surgery. Our phone number is 800-989-8255. Email us, firstname.lastname@example.org. You can also join the conversation at our website. Go to npr.org, click on TALK OF THE NATION, and you can read Dr. Lerner's op-ed there as well. Dr. Lerner joins us now from our bureau in New York. He's a professor of medicine and public health at Columbia University. Nice of you to be with us today.
Dr. BARRON LERNER: Thank you. Nice to be here.
CONAN: And you point out that this HIPEC procedure is just the latest in a long series of very aggressive procedures by cancer surgeons.
LERNER: It is. And for decades and decades, people treating cancer have tried very, very aggressive surgery, aggressive radiation and more recently, aggressive chemotherapy. And the idea, as you suggested before, was to kill as many cancer cells as possible, theoretically doing better for the patient by doing so.
CONAN: Yet you also say they do so on slim evidence, and despite evidence that it may not be better - or may be even worse than traditional therapies.
LERNER: Right. It's a tricky situation because if you don't try to innovate in cancer - or elsewhere in medicine - you'll stay with what you have, and nothing can get better. But what I was concerned about in this case was that it reminded me of other historical episodes where it wasn't just something that was building on early scientific data; it seemed to have more to do with the issue of effort and trying harder, and trying whatever we could no matter how toxic it is, as a way to help patients who are very, very ill and perhaps vulnerable to accepting such procedures.
CONAN: You write: In 1946, Cushman Haagensen warned his colleagues against surgical cowardice in the face of a formidable enemy that is cancer. And Jerome A. Urban, the father of the super-radical mastectomy, was fond of saying lesser surgery is done by lesser surgeons.
LERNER: Yeah. That was the point I was trying to make, that I think we conflate the effort that goes into procedures and wanting to do the best for our patients, with doing the best for our patients at times. And it - as I said, and I use the term well-meaning in the article. I think that the doctors who innovate and do things in this area really want to try to do what's best for their patients. They want to save lives. But sometimes, it has more to do with the culture of fighting cancer than it has to do with helping patients.
CONAN: Fighting cancer - the military metaphors disturb as you well.
LERNER: Yes. They're there, and I'm hardly the first to talk about them. They've been there in cancer, and people like Susan Sontag have written that we need to get rid of them. But they're still here, and fighting, today.
CONAN: And yet, it is important to point out there are a lot of cancer doctors and others - kinds of doctors who say: Wait a minute, just because there is a possibility that this - we need to treat each patient individually, and this might work for some but not for others.
LERNER: That's true. And certainly, anyone getting a procedure like this should get a long, long talk about the fact that it is highly, highly experimental; that there's very, very limited data; and that it's very, very toxic - at least that before they go ahead with it. I also would hope that all this type of experiment would be done in formal trials, so we could figure out whether this thing works or not, rather than doing it purely on patients who are willing to go through something so extreme.
CONAN: So in other words, these procedures aren't necessarily subject to the same kind of procedures a new drug would be subject to?
LERNER: That's correct. You know, I think we'd all like them to be but it's - realistically, it is hard to get - think about this: someone with very, very severe cancer grasping at straws and you say to them, there's this procedure out there but if you enter this trial, there's only half a chance you're going to get the procedure. It's very hard to get people to sign up for that when they can go somewhere else, pay the money, and get the procedure they want.
CONAN: And that even - despite you can say look, as you say, this high-tech procedure, there was a study done in, I think, the Netherlands, but 8 percent of the patients there died from the procedure.
LERNER: Exactly. And this is a very, very aggressive procedure and, you know, it's something that some people that are willing to risk, to roll the dice for. But they just need to know exactly what they're getting into first.
CONAN: And sometimes, is what they need to know is, I'm sorry; there's nothing we can really do?
LERNER: Well, you know, it depends on the doctor you go to. You'll get different recommendations for people. Some folks, I think, with people who have very, very end-stage cancers, would say to those patients - some doctors would say look, I think there's nothing scientifically to offer you. I want to talk to you about things like palliative care and hospice, and being sure you're comfortable. And then other doctors will say, I've got one more thing to try. And different patients will gravitate to different doctors.
CONAN: And the patients themselves will sometimes say, I've read about this procedure in the Netherlands. Why don't we try that?
LERNER: You bet, especially with the Internet. I think myself and all other doctors these days have patients who come in, and they're - I'd like to use the word brandishing data and things that they find on the Internet, and pushing the doctors into things. And I think, as part of being a medical professional, you need to not get pushed into things that you think are not medically appropriate and scientifically valid.
CONAN: We want to hear from doctors and patients with experience with cancer about this issue, 800-989-8255. Email us: email@example.com. Sara's on the line, Sara with us from Denton in North Carolina.
CONAN: Hi, Sara.
SARA: Yes. Seventeen years ago, I was misdiagnosed. The doctor thought I had an incarcerated hernia. It was found to be metastasized melanoma. And because it was extensive, he was convinced that there probably were more nodes involved. He insisted on a deep pelvic node dissection. I did not have resources. There was so much pressure on me to get this done. I was so weak at that point and exhausted and demoralized, and went ahead and agreed to the surgery. It ruined my life. It took away part of my leg. All the things that I needed to do to help process the information, and make a sound decision, were denied to me because he was concerned of malpractice, because I was asking too many questions.
What I'd say is, listen to your body. Respect your own culture. There are ways for us to find clearing of our minds, our souls and our hearts so we can hear the voices that our bodies have, to tell us what may help. And that takes taking time, stopping and paying attention. And everyone is in such a hurry. Don't be in a hurry. I have - every day, I have more difficulty walking. I get infections, each of which is life-threatening. I have turned completely to herbs and homeopathy, and they have saved me from millions of dollars of hospitalization. Fortunately, I have an oncologist who doesn't understand homeopathy, but she supports whatever people turn to for healing that is right for them.
CONAN: Sara, we're so sorry for your terrible pain that you've undergone. But as you listen to her, Dr. Lerner - take time; that'snot something you often hear.
LERNER: Yeah, that's a really good point. What - I was not - I was going to say not only take time, but if you can do it, get more than one opinion. Some days, obviously - sometimes it's too expensive to do that. But if you can get more than one opinion, bring friends, family with you to the appointment. As Sara was suggesting, you're the only person there; you feel vulnerable. You trust the doctor. You don't want to get railroaded into anything, and there is really time. Most people who have cancer in their bodies, it's been there a long time. It's not like you're going to have metastases in a day because you waited to get a second opinion.
CONAN: Sara, thanks very much for the call.
SARA: Thank you for listening.
CONAN: Let's go next to - this is George, and George with us from Columbus.
GEORGE: Yes. Doctor, thank you very much for taking the time to get into these issues. I think they're very important. My wife is a BRCA1 gene mutation carrier. And in 1999, she had her ovaries removed to try and keep from getting ovarian cancer. And in 2004, she was diagnosed with stage 3C primary peritoneal cancer, which - that's the first thing that makes your jaw drop - is, how can you develop a cancer in something that you allegedly had taken out? I understand how that happens, but the cancer journey is really complex, indeed.
But part of her treatment is when she had her first recurrence, intraperitoneal chemotherapy was just coming into vogue. And we opted to have her debulked a second time and have the catheter placed for - I mean, the port placed for intraperitoneal chemotherapy, and that bought her 12 months of remission after she finished that therapy. And I guess what I'm curious about is, are you talking about a situation where someone is still on the operating table and gets chemotherapy while they're still on the operating table? Or are you talking about the classical, you're debulked, you heal, you get a - you're debulked and you have a port placed, you heal, and then you start treatment.
LERNER: Yeah. It's - this is a - sort of the newer version of what you were discussing. This is a separate thing; there's the surgical part and the oncological part. What's new here, in particular, is the heating of the chemotherapy. And there's a rationale for that, which is it's long been known that cancer cells are more susceptible to heat than regular cells. So there is a theoretical basis for this. But you know, the question becomes: When is that appropriate to prescribe? The treatment that you're recommending for ovarian cancer that's extended to the peritoneum has been shown in studies to prolong survival. So that's what we would hope to see in this instance as well.
GEORGE: Got you. And then one other thing, I just caught the tail end of you talking about clinical trials. My wife has been in clinical trials for two years. It's been over two years since she's had to have chemotherapy. And we are sold, sold, sold on participating in clinical trials. She has participated in them at Ohio State University, at the University of Wisconsin, and now at the National Institutes of Health. And we've had good responses in each instance, and I can't say enough good things about clinical trials.
LERNER: That's such an important point. As I suggested before, it's sometimes difficult for people to understand, because they're just one patient or one family, why you would try something that's experimental, and be in an experiment when you're dealing with such a grave disease. And their reasons are, the doctors get the knowledge that they need to learn more about the disease and to treat other people well. So going into clinical trials can help individual patients, but it also helps science. So they are to be commended.
CONAN: George, we wish you and you wife the best.
GEORGE: Thank you very much.
CONAN: We're talking about extreme cancer surgery with Dr. Barron Lerner, the author of an op-ed in today's New York Times, "The Annals of Extreme Surgery." You're listening to TALK OF THE NATION, from NPR News. And let's go next to Michelle(ph), and Michelle's on the line from Cleveland.
MICHELLE: Hi. How are you?
CONAN: Good. Thanks.
MICHELLE: Well, I was calling because I had the HIPEC surgery last year. I was the first that I know of, in Ohio, to have it for female cancer. I have a recurrence of cervical cancer that has spread. And I felt extremely pressured, as if I had no other option. And without having any data to back it up, it was a very scary choice. I was told I may have six months to two years if I had the surgery. Now that I've had the surgery, it's all up in the air. They have no idea. They - since there's no data and I have such an unusual cancer, they really can't tell me, you know, any kind of outcome. And it's very frightening; I walk on eggshells daily. And I wondered if your guest knew much about other people in the world that might have had the HIPEC surgery for any female cancer.
CONAN: Doctor Lerner?
Yeah. I - none of my patients have had it. You know, my guess is if you go on the Internet, you're going to be able to find some women who've had this as well. But your larger point is absolutely correct, that this is - the pushing - you know, we're pushing the envelope here. And women like you, who undergo this surgery, are going to teach us about this surgery. And the promise for an individual like yourself, there's a huge amount of unknown. And one hopes that you're - not only that you continue to do well, but also that we learn from the cases like yours, even if the procedure didn't occur within a clinical trial.
MICHELLE: Yeah. I'm very curious about the toxi - toxi - excuse me, I can't say the name.
CONAN: Toxicity, yes.
MICHELLE: Toxicity of this procedure. It was not really explained to me.
LERNER: They don't - it's partly because it's so new. I think that we're only beginning - doctors are only beginning to discover what the toxicities are. Certainly, chemotherapy has been put into abdomens before, and some of the toxicities would probably be similar when the agents were put into the peritoneum without being heated. So that would be one thing you might be able to look up.
MICHELLE: OK. Thank you very much.
CONAN: Michelle, thanks very much for the call. There are stereotypes, I guess, of every profession. And I guess the stereotype of the surgeon is that there is no problem that cannot be solved with a knife. Do you feel - do you worry that you might be perpetuating that stereotype?
LERNER: Yeah. I'm - I - look, I know a lot of surgeons. I trust a lot of surgeons. They're wonderful doctors. And a lot of the surgeons today, by the way, are at the forefront of trying to minimize aggressive surgery. So the profession is very, very broad. But having said that, certainly, when I was in medical school, there was a type of student who liked to cut and liked to get into things and was more, you know, we might say aggressive and problem-solving than the rest of us. I sort of chose a very cerebral field. And once you get into surgery and there's a lot of gadgets and there's a lot of sick people, the temptation, I think, is to push the envelope and to really see what you can achieve with these new technologies, with new procedures. And while at certain times, these have - I mean, have resulted in great, great successes, we don't hear very often about the failures.
And so it's just - and I think within the world of surgery, this gets talked about a lot these days, and you shouldn't be knife-happy. But it speaks to the larger issue, really, of our culture and not just surgery, where we think - people say we're a death-defying culture. If people have very, very end-stage cancer, in many cases, that's what's killing them, and it's time to die. It's very hard when there is potential technology, and there are doctors who are willing to push the envelope, for people to be able to say no.
CONAN: Dr. Lerner, thanks very much for your time.
LERNER: Thank you.
CONAN: Doctor Barron Lerner, professor of medicine and public health at Columbia University. His op-ed "The Annals of Extreme Surgery" ran today in The New York Times. There's a link to it on our website. Go to npr.org. Click on TALK OF THE NATION. He joined us from our bureau in New York. This is TALK OF THE NATION, from NPR News. I'm Neal Conan, in Washington.
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